GI block i-Human cases 2023 with complete solution questions and answers

Clues about the patient's stool for Ms. Schilling If floating high fat content, if watery the colon is not able to absorb water, urgency also indicates more water in stool Role of the gallbladder for Ms. Schilling Patient had gallstones, gallbladder is responsible for making bile so could be recurrence of gallstones. Gallstones can be stuck in gallbladder and often in the sphincter of Oddi area. This could be the reason for her pain. Differential diagnoses for Ms. Schilling Gluten sensitivity, gallstones, irritable bowel syndrome, pancreatitis maybe (but usually related to alcohol use), substance abuse--possibly laxative abuse in this case, ulcerative colitis, anxiety/stress, cancer, giardiasis (from contaminated water) Significant findings for Ms. Schilling Low albumin (protein) levels (malabsorption), gall stones were present but no signs of inflammation, macrocytic anemia due to low vitamin B12 (malabsorption), positive for glandin IgA and glandin IgG antibodies (Celiac), positive endomysial Ab screen (Celiac) Findings which support Ms. Schilling's diagnosis Diarrhea (with fecal fat) associated with abdominal pain worsened with wheat products, weight loss due to malabsorption, positive antibodies for gliadin and endomysium, to confirm diagnosis obtain biopsy of small intestine via endoscopy (will show flat mucosal villi surface with plasmacytic infiltration of subepithelial region), coagulopathy (deficiencies) 5 complications specific to Celiac disease for Ms. Schilling 1. Malnutrition: if left untreated, happens in spite of adequate diet, deficiency in vitamins/minerals, vitamin D, folate, iron, anemia, weight loss 2. Loss of calcium and bone density: loss of fat in stool causing calcium and vitamin D loss, may result in osteomalacia, osteoporosis 3. Lactose intolerance: damage to small intestine from gluten can cause sensitivities to other foods like dairy, may or may not resolve with gluten-free diet 4. Cancer: if gluten-free diet not maintained greater chance of cancers including intestinal lymphoma and bowel cancers 5. Neurological complications: Celiac disease associated with nervous system disorders including seizures and peripheral neuropathy Normal non-inflammatory response to foods Ms. Schilling case M-cells sample protein digests and present antigens to immune system so that we do not react to these antigens in order to promote tolerance. Celiac disease immune response Ms. Schilling case Not able to fully break down gluten, likely due to high proline content. If perforation in gut barrier then will cause reaction. Antigen recognizing cells HLA-DQ2 HLA-DQ8 recognize gluten. Gluten doesn't quite fit in receptor so TTG needs to change conformation in order to fit. Antigen recognizing cells in Celiac disease Ms. Schilling case HLA-DQ2 HLA-DQ8 What causes Celiac disease? Ms. Schilling case Stress or infection and genetic susceptibility leads to a inflammatory milieu leading to increased antigen sampling. Higher levels of TNF and IL-15 (can turn into natural killer cells in high amounts). HLA positive is driving force then more non-HLA genes cause more or less vulnerability. Genes related to Celiac disease Ms Schilling case HLA-DQ2 HLA-DQ8 on chromosome 6 but other factors important because 40% of population has these variants, not a great screening test. 64 other associated genes in Celiac. 40 of these genes interact with each other and influence TNF and IL-15 Histology and Celiac disease Ms. Schilling case 3 coverings of the GI tract: plicae circulares, villi, microvilli. Blunting and truncation of villi, increase in interepithelial lymphocytes, crypt hyperplasia, lymphocyte infiltration into crypts (they should be in lamina propira) Absorption and digestion factors in Celiac disease Ms. Schilling Specific enzymes and transport proteins on the cell surface of mucosal cells to finish digestion. Less energy coming in and being utilized than usual. Lipid absorption will also be affected due to less cells and villi on the surface. Losing surface area, enzymes, and transport proteins. Micronutrients in Celiac for Ms. Schilling Generalized problem with clotting, slightly low hemoglobin, protein digestion/absorption affected (low albumin which is 60% of protein in circulation), liver function looking ok, pancreatic enzymes are low but in normal level so not playing role in disease of the patient. 4 groups of common deficiencies in Celiac disease Ms. Schilling 1. Macronutrients: carbs, fats, proteins 2. Essential fatty acids and amino acids 3. Minerals: iron, calcium, magnesium, copper, zinc 4. Vitamins: lipid soluble (A,E,D,K), B vitamins, C vitamins